Sunday Snippets

I’m up at the orsm Jonas family’s farm with an incredible bunch of likeminded foodie lefty people.

Sky love at Jonai Farms

A photo posted by Daniel Reeders (@onekind81) on

Beatrice and piggehs

A photo posted by Daniel Reeders (@onekind81) on

I’m up here with the fabulous Linda Kirkman — researcher of friends with benefits relationships among rural heterosexuals over 50, and earlier in her life, Australia’s first surrogate mother.

Here she is in yesterday’s Good Weekend:

I'm spending the day exploring Bendigo with a celebrity!

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Here’s a video interview I did at the AIDS2014 conference with Rex Pilgrim from ACT UP Queensland.  We talk about the three main responses to the media panic about deliberate HIV infection — the criminal law, public health management, and a supportive community response.

Lastly, I got to co-author an article with the incredibly talented Suzanne Nguyen — artist, designer, story collector and provoker of thoughtful conversations about the modern reality of race in Australia.  For Croakey, the Crikey health blog.

Click to visit:  Defining and responding to everyday racism

Word choice matters: ‘prostitution’ and ‘sex work’ in The Hoopla


The Hoopla is an online news and commentary magazine for an audience of politically engaged and ‘predominantly older’ women (Bodey, 2013).  Recently it has published a couple of pieces on sex work that troubled me and I challenged its editor, political journalist and comedian Wendy Harmer, to reconsider its implicit stance against sex work as a profession.  ‘That’s bullshit, Daniel’, she wrote in reply, ‘the Hoopla canvasses all opinions, do a cursory search, you’ll find them.’

The site is notable in the Australian publishing sector for paying its writers, and it has the best paywall in the business — really low friction and a reasonably priced day pass at 99c per day.  The Age and Black Inc, if you’re reading this, nota bene!  So I took Wendy up on her invitation and used the search tool to undertake a quick and dirty content analysis of its articles.

Content analysis is a methodology “by which the researcher seeks to determine the manifest content of written, spoken or published communications by systematic, objective and quantitative analysis” (Zito 1975, p73).  It assumes that patterns in the subject matter reflect the attitudes of the people who create it (Berger, 1998, p23).

These days, the language around “systematic, objective and quantitative” sounds a bit quaint — most researchers are more likely to acknowledge that we bring perspectives and commitments of our own to the analysis, and that textual material is capable of being read in multiple ways, although these readings are themselves patterned by power relations and ideology.

As a writer and researcher around stigma and sexual health I have a particular concern for the way stigma operates to normalise discrimination and inequity in legislation regarding members of marginalised groups (Parker & Aggleton, 2003).

The Lancet shares that concern: in a special edition launched at the AIDS2014 conference in Melbourne, it published a series of studies supporting full decriminalisation of sex work as the best approach to promote the health and wellbeing of both sex workers and their clients.

As then-Prof (now Justice) Marcia Neave found in her inquiry into Victorian laws against sex work in the 1990s, criminalising sex work makes sex workers vulnerable to violence and extortion by both clients and police.

The same dynamic is found in laws criminalising sex between men: if consensual sex is illegal, and you are beaten up or blackmailed in connection with it, you can’t seek help from the police without making an admission of criminal wrongdoing.

In places where the law prohibits purchasing sexual services, as it does in many American states and Nordic countries, it creates an incentive for clients to drive with sex workers to places where police are few and far — an unsafe environment for workers if the client turns violent.

Laws that prohibit making any kind of a profit from another person selling sexual services also tend to apply to managers, cleaners and security staff.  The presence of ‘pimps’ and protection rackets is more likely when it is not possible to treat sex work as a legitimate business with all the administrative, security and occupational health and safety overhead support.

Finally, criminalising sex work creates a bigger ‘haystack’ in which to find the needle of people being trafficked.  This is one reason why Denmark, which decriminalised sex work in 1999, apparently finds four times as many trafficked people than Sweden, which has a much larger population and criminalises the purchase of sex.

I got that last factoid from an article by Gabrielle Jackson in The Hoopla (2/9/14) titled “The real cost of selling sex”, but I used my training in epidemiology to flip it around: more reported cases doesn’t mean Denmark has a worse trafficking problem; it could actually mean they’re better at finding trafficking cases.  (For the same reason, you can’t look at an increase in HIV diagnoses and ‘read off from the numbers’ what it means for rates of new infections.)

In her book Sex and the Margins (2007) Laura Agustin points out the many reasons why it’s tricky to nail down hard facts about so-called ‘trafficking’.  So hard, in fact, that the main index on trafficking actually measures worldwide media reports on the issue, rather than any primary data source on persons found to have been trafficked.  In due course, Jackson’s article and the many, many others like it — articles reporting on other articles — will be taken as proof that trafficking is on the increase.


Every time a journalist and her editor write about sex work on The Hoopla, they make word choices that reveal underlying attitudes and value judgments towards that topic.

I’m using a tactic I developed in my work around ‘sexual racism’ in the gay community, where many people argued that saying “No Asians” in their profile simply reflected a diversity of opinion their preferences for a particular body type.

Since it costs literally nothing to choose a more neutral phrase (“Prefer white men”) over the other (“No Asians”), I conclude they must have intended the negative judgment implicit in the latter, even if they don’t admit it to themselves.

I use market theory a lot in my work on sexual racism and in technical terms this is the linguistic equivalent of “revealed preferences” in the economic analysis of purchasing behaviour.  Yep, word choices are purchases: they buy different amounts of grief from different audiences with different material and symbolic interests in the subject.

In the analysis that follows I’m looking at patterns in the word choices made by The Hoopla in its coverage of sex work.  Given that it has multiple writers, I want to know what its average way of describing sex work is, as well as the range of different stances it takes on sex work, as signalled by those word choices.

I do this by counting the word choices: sex work or worker vs. prostitute (noun or verb) or prostitution, taking care to differentiate between authors using a term themselves vs. quoting an interviewee or secondary text using the term.  I created a spreadsheet where you can view how I coded the articles and the key quotes from each one.  I used the search tool available on with a 99c day pass and I coded every article it returned.

In particular, from a semantic perspective I’m interested in what differences do their writers observe between sex work and other practices like trafficking, child abuse, and rape? — given that many anti-sex work advocates like Kajsa Ekis Ekman argue there is an essential continuity between paid sex work and human trafficking since, in their view, humans are ‘bought and sold’ in both.  This analysis is inherently more open ended than the quantitative analysis of word choices; reasonable people could disagree on the interpretation so I spell it out here and I welcome constructive responses in the comments below.


Word choices

I found 45 articles making a word choice between ‘sex work’ or ‘prostitution’.

  • In three articles (7%) the author used ‘sex work’ or ‘sex worker’ exclusively.
  • In one article (2%) the author quoted someone using ‘sex work’ or ‘sex worker’ exclusively.
  • In nine articles (20%) the author used both ‘sex work/er’ and ‘prostitute’ or ‘prostitution’.
  • In six articles (13%) the author quoted someone using ‘prostitute’ or ‘prostitution’ exclusively.
  • In 26 articles (58%) the author used ‘prostitute’ or ‘prostitution’ exclusively.

Takehome: these numbers do not support Wendy Harmer’s view that The Hoopla canvasses diverse opinions on sex work.  By an overwhelming majority, the articles on The Hoopla represent sex work as prostitution.  This is discussed further below.

Two articles either by or featuring Gabrielle Jackson went full flush: the author used and quoted people using both forms.

Themes and differences

1) Dead prostitutes as entertainment for The Hoopla‘s readership

In my tweet about ‘rough cut results’ last night I drastically undercounted the number of times the site mentions ‘prostitutes’.  I thought there was something hinky about the search function; it was returning a whole bunch of book reviews in error.

Turns out… not an error.  Eleven results for ‘prostitute’ were for synopses of novels reviewed by Meredith Jaffe, who might just need PTSD counselling by now.  Have a read and see if you can spot the theme.

“In the Newgate prison, four young women are allied by their need for friendship and protection in a world where life is fragile and, if no one is there to watch you back, it’s short as well. Loud, brave prostitute Friday Woolfe is their protector.”
“Bestselling, award-winning mother/daughter writing team P.J. and Traci Lambrecht aka P.J. Tracy are back with another nail-biting thriller, Two Evils. A group of young Native American girls are abducted from their reservation, fresh fodder for under-aged prostitution.”
“A suburban madam is found dead in her car supposedly having committed suicide and a few suburbs away, Heloise Lewis has more than a passing interest in the woman’s death. Heloise is very careful about blending in. As far as her neighbours are concerned, Heloise is just another suburban mum, a young widow who works as a lobbyist for pay equity for women. No one knows that Heloise is also a suburban madam, she’s just a lot more careful about how she runs her business than the dead prostitute.”
“In the late 18th century in the south of India, a daughter Maya is born into a family of devadasi, the temple dancers who are married to Shiva and thus regarded as a higher caste even as the priests and brokers prostitute them to wealthy patrons.”
“Because she is the daughter of the town prostitute, she does not seem to be an especially valued resident, and many of the locals are dismissive of what has happened.”
“Into their circle enters a stranger, the Scottish lawyer Walter Moody, himself travelling under a false name and escaping a past that has transpired to follow him. At question is a murder, a prostitute found half dead on the road to Arahura, a missing trunk, a stolen identity and the whereabouts of one Emery Staines, a wealthy gold digger cum business man.”
“At question is a murder, a prostitute found half dead on the road to Arahura, a missing trunk, a stolen identity and the whereabouts of one Emery Staines, a wealthy gold digger cum business man.” / “On the Gulf Coast of Texas after the American Civil War, a prostitute called Lucinda steals out of the bordello in which she has been a virtual prisoner, and sets course for Middle Bayou.”
“Some weeks after Angie’s death, a girl was found dead in Kings Cross, killed in the same manner. Kelly was a homeless teenage prostitute, a heroin addict and there was nothing to link the two murders except the killer’s use of a scarf tied in a distinctive manner. But Erin knows the murders are connected and she is determined to find out which member of Jane’s family holds the secret.”
“Jade’s mother is a drug addicted prostitute and when she dies of an overdose, it is Banjo’s family that takes the wild teenage orphan in.”
“The wealthy and powerful Cavanagh family has put a price on Mak’s head. She asked too many questions about the dead Thai girl found in a dumpster and the Cavanagh heir Damien’s involvement in the illegal, under aged prostitute’s death. “
“But when prostitute Jane Delaney turns up in the morgue murdered and detectives Butch Bonnie and Rick Landry identify her as Lucy Bennett, Amanda and Evelyn decide to risk their almost non-existent careers and investigate the crime.”

Prostitute. Dead prostitute. Half dead prostitute. Underaged prostitute. Prostitute on the run. Missing daughter of town prostitute. Homeless teenage heroin addicted dead prostitute.

Seems The Hoopla are plenty happy to recommend as light entertainment a book in which a dead prostitute is a plot device.

More seriously, all of these hackneyed plots reinforce a single Judeo-Christian moral: the wages of sin is death.

2) Blurred lines

Articles in The Hoopla repeatedly fail to distinguish between sex work — sex between consenting adults for money — and rape of children or adults.  There’s something particularly obscene in referring to ‘underaged sex work’.  That’s child rape.  Likewise, ‘forced sex work’ is multiple rape.  Examples include:

“They talk candidly – *intimately* – to camera about their issues of the moment: getting married, having a baby, graduating from school, being forced into prostitution, living with violent oppression.” and “In Cambodia, child prostitution, in the projects of New York, drugs and gang violence, in Sydney, the lure of suicide.” (The Hoopla, 30 Aug 13, “I am a girl. I need to be seen.”).

“Bestselling, award-winning mother/daughter writing team P.J. and Traci Lambrecht aka P.J. Tracy are back with another nail-biting thriller, Two Evils. A group of young Native American girls are abducted from their reservation, fresh fodder for under-aged prostitution.” (Meredith Jaffe, 1 Feb 13, “January’s top 5 Aussie books”).

“In the late 18th century in the south of India, a daughter Maya is born into a family of devadasi, the temple dancers who are married to Shiva and thus regarded as a higher caste even as the priests and brokers prostitute them to wealthy patrons.” (Meredith Jaffe, 28 Jun 13, “The silent book club”).

‘Just like the Australian man who married a woman from Iraq and brought her back with the promise a “new life”. “When she came to Australia she was locked up in a hotel room and the husband then started bringing his friends and acquaintances and forcing his newly acquired wife into sexual servitude, into prostitution.”’ (Antoinette Lattouf, 25 Oct 13, “No say in her future”).

One quote in particular demonstrates the conceptual slippage that occurs when anti-sex work advocates paint consensual sex work and sexual slavery with the same brush:

“Would women choose sex work if they had well-paying options with real work flexibility? It is difficult to think about sex workers in the west without thinking about sex work in developing countries, and how many girls and women are traded/forced/raped/abused sexually. Often, for them, being in the sex industry isn’t a choice.” (Catherine Walsh, 18 April 2014, “Should we turn off the red light?”)

In fact, at the recent International AIDS Conference in Melbourne, a sex worker from Africa said in a plenary, “please stop buying me sewing machines. I could afford to buy ten sewing machines — if I cared to get paid $3/hour.”  For many women, sex work is the well-paying option with real work flexibility.  

But the author quickly skates away from her own question to raise the more emotive issue of “girls and women (who) are traded/forced/raped/abused sexually”.  When emotions are raised, our guard goes down, and perhaps we don’t notice that a paragraph that begins talking about “sex work” ends with “being in the sex industry isn’t a choice” for some women.

It matters to use terminology that recognises a difference between sex work and rape or trafficking. For many people who support decriminalising sex work, a key reason is that it makes it easier to spot illegal practices. Research shows that when sex work is not illegal in its own right, male clients of sex workers actively participate in reporting suspected coercive practices.

Lastly, I’d note that all five quotes above concern non-white women being forced into sexual slavery.  There is absolutely zero demand for narratives about a highschool teacher in California who has been sacked and now lives on minimum wage because she has a rap sheet for an arrest for soliciting, even though she was never tried or convicted.  

On the other hand, there is so much demand for narratives that tug at the heart strings and feed into White Saviour Complex, they have led to moral entrepreneurs like Somaly Mam creating the narratives and coaching people to recite them for Oprah.  This is an example of what Chimamanda Ngozi Adichie calls “the danger of a single story” about the developing world.

3) Prostitution as pejorative

Another article by Meredith Jaffe (12/10/12, “The Hoopla Literary Society”) talks about how a publisher loses its $500K advance when Julian Assange decides not to go ahead with a book deal, announcing “All memoir is prostitution”.

This illustrates the pejorative moral connotations of the word “prostitute”, which have their roots in Judeo-Christian morality, and underpin the argument of neo-conservative feminists like Kajsa Ekman and Gail Dines.  They express the idea that sex work is “selling the self”, rather than being paid for a skilled service for a particular period of time on terms and conditions. 

This is apparently a problem exclusive to sex work and not, say, working for a major law firm, or in immigration detention.

Further, in one of the quotes under (2) above, priests and brokers prostitute the temple dancers to wealthy patrons.  This points to the inherent ambiguity of saying ‘prostitution’ as opposed to ‘sex work’.  You can prostitute someone else to a third party; the term is inherently transitive. 

Sex work is by definition paid and consensual.  If the sex is not consensual, it isn’t work, it’s rape.  The concept of work comes with expectations around free agreement to a contract, a fair wage and safe working conditions, all of which can and are currently protected for sex workers by the institutions of workplace relations and occupational health and safety.

That’s why it’s so disappointing to read this by Caroline Baum:

“Whether you call that semantics or simply rebranding it’s a bit like prostitutes calling themselves sex workers. It’s true, but it’s not the whole story.” (17 July 2012, “Don’t dance at my funeral”).

Also, frankly, I call it a bit weird, in an article about funeral arrangements.  


The results and discussion here suggest The Hoopla needs to have a think about how it talks about sex workers.

Calling sex work prostitution is at best hopelessly loaded and ambiguous.  At worst, proposals to criminalise it smoosh together sex work and rape/slavery — as if sexual consent didn’t make a difference between them.  That might make sense in some neo-conservative feminism informed by Judeo-Christian values that see a sex worker as a ruined woman, but it doesn’t make any kind of sense within progressive, sex-positive feminism — the kind I was brought up to practice and believe in.

I’ll leave it there.  Please feel free to leave constructive responses in the comments section below.  

Telling tales and talking-through

It seems like mainstream society has finally caught on to the way HIV treatments brought an end to the AIDS era and ushered in the age of living with HIV.  Eighteen years late to the party, but to borrow a great line from the The West Wing, let’s just celebrate the fact they showed up at all.  

As I noted in my last post about the “Bareback Backlash”, it has been hard, in the meantime, to do prevention messages about sex without condoms when our funders can open The Age and find Karen Kissane talking about unprotected sex as “Dancing with Death”.  

As Dion Kagan notes in Kill Your Darlings there has been a recent wave of films and television events, for a combined gay and heterosexual audience, in an emerging genre of “AIDS nostalgia”.  I’m thinking of films like Dallas Buyers’ Club and television series like Angels in America and The Normal Heart.  

I’m not sure these are unprecedented; there was The Hours before them and Rent and Philadelphia, etc, but I agree there’s a sense of a moment around the recent crop — a recognition that the AIDS narrative is out of date and something new needs working through.

In a panel discussion talk at the Emerging Writers Festival, Dion described the way these televisual events function as cultural handles on the phenomenon of AIDS for those who live at some considerable remove from it.  He’d mention at a barbecue writing his PhD on AIDS and barebacking and people would ask “Oh, have you seen ______?”  

This made Dion the perfect person to host another discussion, provocatively titled “AIDS is Dead; Long Live HIV!” at the Melbourne Writers’ Festival, featuring Elizabeth Pisani, author of The Wisdom of Whores and Indonesia Etc and Colin Batrouney, Director of Health Promotion, Policy and Communications at the Victorian AIDS Council.

Dion asked Colin Batrouney what people ask him at barbecues; Batrouney got a good laugh by saying “People put on their compassion face” (he mimics this) “and say, Oh, that must be very hard.”  

Elizabeth Pisani said she proposed the session title out of the desire for people to recognise how the reality of HIV has changed.  She tells of asking a friend of hers, a Frenchman, on third-line treatments that occasionally interfere with his life, what was the greatest hardship he suffered last year.  He thought for a while and said, “Some friends of mine were going skiing and it was the day of my appointment with a doctor, so I had to miss a day of skiing.”

Pisani snarkily imagined an HIV prevention campaign message: “Don’t get HIV or you’ll miss a day of skiing.”

Dion asked Batrouney if he was nostalgic for a time when the prevention message was simpler: “Use a condom every time”. Colin recalled an answer he gave at the Understanding What Works and Why workshop at AIDS2014, noting there has never been some Arcadian moment of the AIDS epidemic when everything was simple; every moment has always been the most complex moment ever.

This remark is right on the money: it nails what’s most pernicious about that heterosexual AIDS nostalgia — the symbolic violence of the wistful imagination of a time when those naughty gay boys were scared straight, frightened by the threat of death into using condoms and forgoing their perversions.

This desire is visible in the support of many conservatives for marriage equality: AIDS as stick, gay marriage as carrot.

As the Social Aspects of the Prevention of AIDS study showed, way back in the early 90s when deaths from AIDS were at their peak, gay men were still having sex without condoms — in the name of intimacy, resistance, survival.

So it was frustrating that the only prevention message that Elizabeth Pisani can imagine is one based on fear.  

Pisani spoke favourably of the New York Department of Public Health campaign “It’s never just HIV”, which threatens an audience imagined to be unafraid of HIV with side effects and co-infections.  Watch for yourself:

Every time Pisani talked about “a prevention message”, it was about motivating people through fear of negative consequences.  If you share that view, it seems a huge problem that the consequences of HIV are now much less serious than they were.  

Indeed, Pisani described the role of AIDS service organisations in developing prevention campaigns and promoting awareness of the modern lived experience of HIV as “diametrically opposed”.  And she thought the NYDPH campaign was pulled because “poz orgs objected it was stigmatising”.  

I can assure you many HIV-negative people voiced strong objections to the New York ad; I was one of them.

It’s pretty fucking fluffy logic to imply, as I heard Pisani doing, that people living with HIV have some conflict of interest when they object to a message targeting HIV-negative people as stigmatising.  

HIV-negative people are affected by stigma too.

When a campaign depicts us all as party boys who don’t think about our health — reproducing that ‘naughty boy’ stigma I describe above — there are two options:

  1. react against the ad and reject the message as well;
  2. or — believe it.

There’s hard research evidence of people doing option (1) when fear campaigns are too graphic.  I’ve argued this effect is likely to apply to messages that provoke shame or reproduce stigma too obviously.

But option (2) is the real worry.  It acts against the most crucial variable in health psychology: self-efficacy.  It also challenges the idea that gay people might work together — in the bedroom or sauna cubicle, or in organisations and online, to prevent HIV because we care about ourselves and others.

If you’re hosting a writer’s festival, you should definitely try to book Elizabeth Pisani.  She is a dream guest.  She is funny, gorgeous, she tells a cracking yarn, and yet she is simultaneously infuriating.  The ingredients of the perfect twitterstorm.

Her book The Wisdom of Whores displays her ability, as a journalist turned epidemiologist, to tell a yarn that conveys an understanding of some pretty complex concepts.  I just loved her description of a night out in a red light district in Indonesia, the chicanery needed to keep fat, corrupt policemen from impounding her blood tests, her canny knowledge of her research assistants and the role a tight pair of jeans can play in recruiting participants.  And I especially love and admire how, by the end of the chapter, the reader knows more than they realise about sampling bias in research.

This ability was on display at the forum.  And so was its dark side: the way a yarn, a canned tale developed in advance and trotted out on cue, is the opposite of ‘thinking-through’.  At the end of a good yarn, all the loose ends are neatly tied up.  But that’s not what we needed.  At this particular ‘moment’, we need talking through.

In the lovely words of a friend from Zim, with some issues you can tug on a loose thread and the sewing machine falls out.  One such issue is Pre-Exposure Prophylaxis — taking HIV meds when you are negative, so that if you’re exposed to the virus, it can’t get a foothold and you’re protected from infection.  

Evidence shows it works if you take it everyday.  (File under ‘obvious’?)  It changes everything, though, to have something to offer gay men who gave up “use a condom everytime” as personally and relationally unsustainable.

When the topic of PrEP came up, Pisani nodded, smiled wrily and told a self-deprecating tale about her own inability to remember to take the pill on time everyday to prevent the life changing consequences of having a baby.  She noted that PrEP uses Truvada, which she called a three drug combination that’s commonly used in first-line treatment in the developing world.

Except that’s not Truvada, that’s Atripla.

If gay men were as ‘sloppy’ in her words as she is about the pill, she worried, this could lead to resistant ‘strains’ of HIV developing and circulating in the developed world, putting the global response to HIV at risk.

Except that’s not how HIV resistance works; that’s a bacterial resistance model.  (More in a future post on this.)

The problem with a yarn is the way it crystallises the time when first you tell it.  Everytime you repeat it — and for an author on a book tour, I’m guessing that happens a lot — you’re taking the audience back in time.

A tale is a TARDIS.  Telling tales is time travel.

Quite frankly, Pisani told an audience a bunch of tales that were easy to understand but more or less out of date.  

This happens easily when you’re on the fringes of the HIV response: you miss out on the fast-moving central current of prevention science and policy development sweeping away old understandings of treatment and prevention.  

Thus the challenge for people working in prevention is to engage with journalists and policy-makers to ‘spin out’ new understandings in formats that non-experts can get their teeth into.  My money is on personal narratives and feature journalism for the job; 500 words with a news angle isn’t space enough to challenge anyone’s assumptions.

Personal narratives work too because, as research into mental health stigma shows, it only takes a small amount of personal contact to enable people who consume stigmatising media narratives to ‘triangulate’ them with reality.

A trickier challenge is getting people who see themselves as ‘hard’ scientists (or hard-nosed ex-journalists) to appreciate the ‘soft’ science of community-based health promotion.  

For example, to convince them why fear isn’t a useful messaging strategy, or why targeting HIV-negative people’s self-interest and identity might not work as well as more relationally premised messages.  

Or, hell, just to understand that ‘stigma’ and ‘community’ are both concepts about emergent causes and the inability to provide a pat one-sentence definition doesn’t make them fluffy and useless.

“We need to talk about fucking and getting high” is a great line, but prevention was never that simple.


Edit:  if you’d like to read more about stigma, I have an article about the technical challenges of defining and measuring HIV stigma in this week’s Eureka Street, the Jesuit Publications e-journal of current affairs, social justice and social policy.

This is a low-frequency blog so please click Subscribe in the left-hand column to get an e-mail when there’s a new post!

Nine reasons why I don’t give a damn

…about your ill-informed ‘personal opinion’ about PrEP.

Writer and lecturer Conner Habib, author of this great piece about sex-phobic reactions to his work in gay porn, today posted a link on his twitter feed to this sex-phobic piece about PrEP.

In August 2009, I went to the National LGBTI Health Summit in Chicago and took part in a panel on HIV stigma with Erik Libey and Tony Valenzuela, talking through some work I did on behalf of the Australian Federation of AIDS Organisations.

The summit included another great panel on bareback porn, recorded by Feast of Fun at the Center on Halsted. It was great to be there and talk with my North American colleagues about HIV risk reduction strategies, rectal microbicides, the Swiss Statement, and a new application of HIV treatments just entering clinical trials, called PrEP.

I had the great privilege of spending some time in conversation with Tony, subject of the Rolling Stone article “They Shoot Barebackers, Don’t They?”, and Amber Hollibaugh of Queers for Economic Justice.

We talked about the emotional sustainability of working in HIV prevention for AIDS service organisations (ASOs). The puritan, sex-phobic culture of North American public health practice makes too many things unspeakable and leads to a performance of evidence-based practice that chokes off funding to community-building strategies that actually work.

The result is pent-up frustration and, every few years, it is unleashed in a community-, sector-, and nation-wide cataclysm centring on some issue that, by a process of metonymy, is made to stand trial for everything that’s wrong with HIV prevention.

Tony had been the touchpoint for an earlier firestorm around the first public acknowledgment of bareback cultures in the mainstream media and his efforts to single-handedly establish the now-unremarkable category of the HIV-positive porn star.

There was concern at the time that a similar process might start up around non-condom strategies for HIV prevention. Sure enough, five years on, moral entrepreneurs like Michael Weinstein from the AIDS Healthcare Foundation are engaged in a concerted effort to spark off a national panic about PrEP, and there’s an emerging divide among gay men that threatens to crystallise into stigma.

This is staggeringly unhelpful, as the case of barebacking will demonstrate: even as behavioural surveys showed unprotected sex with casual partners increasing, gradually but steadily, in every developed country that collects the data, ASOs struggled to promote messages about how to reduce the risk during non-condom sex, because the moral panic about barebacking in the gay community and mainstream media made even the most cautious messages controversial.

Note that I’m not taking a position on casual non-condom sex: just saying that if it’s happening, ASOs should be able to respond honestly and effectively, and the strongest response is a strategic combination of messages. The drum beat is condom reinforcement (and promoting negotiated safety) for those who only do it occasionally with casual partners (or more regularly in relationships). The melody is a cultural narrative around the changing nature of HIV. The instrumental solo is reliable information about non-condom risk reduction strategies for people who, as a matter of disposition or personal difficulty with condoms, prefer exclusively non-condom sex.

In a short and altogether predictable exchange of views on twitter, I was challenged to engage more fully with the nine reasons given in the article Conner tweeted. So here goes: why I don’t give a damn if one person says he will never, ever use PrEP. (His reasons in bold.)

  1. Money. Just because your health insurance doesn’t cover it now, Zach, doesn’t meant it never will. If you have trouble using condoms, it’s a lot cheaper to pay for you to take PrEP than for full HIV treatment after you seroconvert. In particular, it will be a lot cheaper in 5 years when the patent monopoly on the key drug Tenofovir expires.
  2. Trust in pharmaceutical companies. Zach says he’s skeptical because Gilead makes HIV prevention and treatment drugs. There’s a missing premise here, explaining why that’s a problem. But in fact it’s the same drug used for both purposes.
  3. Zach likes condoms. Good for you, Zach. Not everyone does. The hidden premise here is that Zach thinks gay men are going to be choosing between condoms and PrEP, when in fact PrEP is likely to be used by men who either cannot or choose not to use condoms.
  4. Zach is forgetful. This is a pretty good reason for Zach not to use PrEP. In the iPrEx study, although 93% of respondents said they took the drug everyday on time, monitoring drug levels in their blood suggested only 51% actually did. [reference] There are now trials underway exploring alternative dosing strategies for PrEP agents, such as monthly injections and slow-release implantables.  There is actually a huge amount of knowledge about how to solve this problem, if we only looked at research into hormonal birth control practices among women.
  5. Side effects. Everything from joint pain to kidney problems have been reported. Also: Nausea, diarrhea, and skin discoloration.” Truvada has been studied for PrEP because it has the fewest side effects of any combination treatment. Its side effects include bone mineral density loss leading to increased risk of bone fractures, and kidney problems, both of which can be monitored.  The other side effects Zach mentions are from different drugs not used in PrEP.
  6. Truvada makes it harder to find somebody to fuck. A drug most people take in order to have safer bareback sex “limits me to only having sex with men willing to go bareback.” Well, in practice, yes — but there’s no reason someone taking PrEP could not also use a condom.
  7. The difference between condoms and bareback sex is negligible to Zach. Zach did something rather slimy in this piece: he frames it as “personal reasons why I will never, ever use PrEP”. That’s just a pretext to write a bunch of stuff about how PrEP sucks. Why bother doing that if you’re already determined never to use it? The use of the second person voice in the point gives the game away: this is really about what Zach thinks other gay men should do. He writes: “If wearing a thin layer of latex is that difficult for you, maybe your problem is psychological, not physical.” (Emphasis added.) The question I’d pose in return is: so what if it is psychological? Or cultural? Or emotional? Or even just that you prefer raw sex? 
  8. The science is still out. Zach imagines a scenario where, out of the 2499 gay men who took part in the iPrEx trial, only the half who were not receiving the placebo somehow figured that out and only had sex with negative men, and that’s why they had fewer HIV infections than those who received the placebo. This betrays ignorance about how clinical trials work but also gay men’s sexual cultures. Most of the men in the trial and control group would have sought out self-declared HIV negative men for bareback sex; it’s called serosorting and it’s not new. If serosorting worked as perfectly as Zach imagines, however, we wouldn’t need PrEP.  We need it because some proportion of the men who think they’re negative are not — they’ve been recently infected and their viral load is sky high.
  9. The risk of other STIsZach lists a bunch of STIs, including syphilis, herpes and HPV — which are, newsflash, not prevented by condoms, since they can be spread by skin contact with a lesion not covered by a condom. Many people wrongly assume that condoms prevent any STI transmission. In fact, they mainly prevent HIV transmission.  Bacterial STIs like chlamydia and gonorrhea can also be passed on via oral-anal contact during rimming and oral sex without a condom. That’s why we recommend testing for HIV and other STIs at least once a year and every 6 or even 3 months if you’re a really busy boy.

Ironically, one of the things Zach counts against ‘the science’ on PrEP (at point 8) is the prevention effect of HIV treatment among known-positive partners, which is another one of the risk reduction strategies we were talking about at that conference in Chicago.

Neither one is new, exactly. We’ve known since the late 90s that HIV treatment in positive people probably reduces transmission efficiency. Negative people have been prescribed a month-long course of HIV treatments as post-exposure prophylaxis (PEP) since the early 90s, and PrEP is just ongoing PEP. So why did it take so long to consider studying and formalising them as HIV prevention strategies?

Two main reasons. The ‘bareback wars’ made non-condom risk reduction strategies unspeakable. The bareback wars were due, in turn, to people, both gay men and public health practitioners, forgetting that the goal of HIV prevention is to prevent HIV infections using all the means available, not to promote a religion of consistent condom use and demonise those who don’t adhere to it.

Self-care strategies for social media users

A friend in her early twenties announces she’s joining twitter to debate feminist issues.

A leader in my field contacts me by e-mail to ask about my tactic of staged withdrawal from my twitter account, @onekind.

I tell my therapist about my battles on twitter and she laughs and calls it ‘Angry Birds’.*

We need to talk about the emotional sustainability of social media.

Continue reading

A big pharma gaffe

A recent article in Bloomberg Businessweek is sympathetic to the perspective of research pharmaceutical (RP) companies, who face the prospect of India deciding to compulsorily license their patents on three of their blockbuster drugs, for diabetes, HIV and arthritis. It fails to even mention that India is allowed to do so, under WTO rules established by the Doha Declaration, as a developing country in cases of public health emergency.

India is certainly taking an expansive view of what counts as a ‘public health emergency’, but one consistent with the values expressed in the Alma-Ata Declaration on Health for All (WHO, 1978) (PDF) and the growing recognition of non-communicable diseases (NCDs) such as breast cancer, diabetes and arthritis in developing countries as an emerging global health crisis.

In characteristically blunt language the Dutch-born CEO of Bayer AG denounced the Indian proposal:

Bayer Chief Executive Officer Marijn Dekkers called the compulsory license “essentially theft.”

“We did not develop this medicine for Indians,” Dekkers said Dec. 3. “We developed it for western patients who can afford it.”

This is an exceedingly callous remark from the leader of an organisation that claims to be “committed to operating sustainably and addressing our social and ethical responsibilities as a corporate citizen.” (source)

However, it can also be understood as a Kinsley gaffe revealing the essential correctness of the balance struck in the Doha Declaration. This refers to the situation when “a political gaffe reveals some truth that a politician didn’t intend to admit” (Wiki) — in other words, the accidental release of too much truth.

The truth accidentally revealed in Dekkers’ remarks is that Bayer AG has very little to lose by compulsory licensing in India, because it never anticipated much profit there in the first place.

What’s actually going on is less about protecting the revenue from blockbuster drugs in countries where most can’t afford them anyway, and more about protecting and extending the length of patent coverage in developed countries.

Christopher Scott Harrison, in The Politics of the International Pricing of Prescription Drugs, describes lobbying by the Pharmaceutical Research and Manufacturers Association (PhRMA) to use global trade law and negotiations to export, and therefore, crucially, re-import, regulations that are tougher than the US Congress would be willing to vote for domestically.

This strategy follows on from the extraordinary success of book, film and music publishing industries in copyright term extension, twenty years at a time, so that profitable properties like Disney films and To Kill a Mockingbird never revert to the public domain.

When patent laws were first enacted, their framers sought to strike a compromise between the interests of developing industrial societies — which at the time included the United Kingdom and United States — in widespread access to new technologies, and allowing sufficient monopoly period with windfall profits as an incentive to inventors.

This calculation should always be kept in mind; it clearly supports the case-by-case breaking of patents to provide enormous benefits to people in countries which offered little prospect of windfall profits in the first place.

What we’re seeing now is the use of international trade agreements to strengthen a regime that seeks to revise this balance in favour of research pharmaceutical companies. It is accomplished by means of the original WTO agreement on Trade Related Intellectual Property Rights (TRIPS), unilateral trade sanctions of questionable legality applied via the US Trade Representative’s watch list procedure, and more recently, a variety of bi- and multi-lateral trade agreements, potentially including the Trans-Pacific Partnership Agreement.

Although progressive activists have long viewed the WTO through a lens of ‘bigger is not better’, the shift towards a patchwork of bi- and multi-lateral investment agreements probably reflects a feeling in the US that WTO processes affords too much bargaining power to developing countries.

I have some sympathy myself for research pharmaceutical developers — they have to gamble big money on very uncertain outcomes, although perhaps not as much as some have claimed, and drug research and development is getting harder and more complex, because the easy discoveries may have all been made: the ‘low-hanging fruit’ has been picked. 

But some are in such tricky corporate terrain because they pursued a decades-long spree of ill-advised mergers and acquisitions, and seeking ever-longer patent terms looks, in this light, like a clear-cut case of rent-seeking.

Rape law doesn’t work—by design.

In something like my sixth year in law school I took a two-unit subject, Advanced Legal Research, to write about options for reforming the criminal law against rape.  I failed it, not once, but twice. I got so depressed I couldn’t write. Not only does the law against rape not work, from a history written by Barbara Hanawalt I discovered it was more or less designed not to work.

Rape was first made a crime in the first Statute of Westminster — kind of the first codified criminal law — out of concerns that too many women were making appeals against rape.  An ‘appeal to the reeve’ was a form of private prosecution, although there was nothing private about it — ‘reeve’ was a hundred or so local worthies, all men, to whom she had to proclaim (announce) her rape pretty much as soon as it happened, evidenced by ‘torn clothes and effusion of blood’, and then to bring it before the next county court.

The crime was enacted into the Statute of Westminster in order to reduce the ability of women to appeal it.  Although rape is often described as a property crime — since marriage was one of the ways to make a rape complaint go away, there was concern that rape could be falsely appealed to secure a marriage — in this light it makes sense to view the criminalisation of rape as a strategy for maintaining public order.  The crime gave a woman forty days to appeal her rape, otherwise only the Crown could prosecute it, and then the sentence was up to two years’ imprisonment.

Clearly there was some kind of outcry, for ten years later, in 1285, the Statute of Westminster II prescribed a sentence of punishment in life and member — execution and/or punitive amputation (possibly castration).  But in response, Hanawalt suggests, court procedure seems to have developed to make it more or less impossible for a woman to secure a conviction.  She had to tell and retell her story at each point from the reeve to final appeal in exactly the same words, else she would be deemed a liar and subject to punishment herself.

And yet somehow by the seventeenth century we have the Lord Chief Justice Sir Matthew Hale pronouncing “rape…is an accusation easily to be made and hard to be proved, and harder to be defended by the party accused, tho never so innocent”, and then that becoming part of the standard jury directions for rape trials in Australia.  This is a guy who believed in witchcraft but not the possibility of marital rape, and is yet esteemed one of the leading lights in the development of common law.

This is about as far as I’d got before I was unable to write for the rage I was feeling.  Didn’t even make it to the eighteenth century.  We have seven hundred years of a crime that was written expressly to restrict the ability of women to prosecute rape.  My home state, Victoria, is known as an innovator in rape law reform because it introduced jury directions that defined sexual consent as ‘free agreement’.  This was seen as some huge innovation, even though it left intact the elements of the crime, which said that what mattered was what the defendant believed about consent, not whether consent was actually present.

There has been some more recent fuckery in other jurisdictions about whether the belief was reasonable or not, i.e. did the defendant have evidence of consent or make enquiries.  But again, that simply invites the jury to substitute its own judgment for the defendant’s, when the judgment that matters is the victim’s.

One of the most depressing things was an article by two lifelong advocates for rape law reform who said frankly, if a friend or family member asked if it was worth making a rape complaint in their state (South Australia), they would have to say no.  Another author looked at the appalling conviction rate and concluded that certain juries seemed to be agreeing with the victim that she experienced rape, but feeling unable to find that, on the elements of the offence, the defendant was a rapist.

After I failed those two times I permanently gave up on wanting to become a practicing lawyer, and returned to working as a health educator in sexual and reproductive health, where there isn’t the need to bind up a sensible message in all the accumulated bullshit of seven hundred years of dysfunctional statute and common law.

But I remember wishing there was an intermediate offence of sexual assault, an alternative charge that could be pled along with rape, so that if a jury found itself in that situation — the impossibility-by-design of proving a rape charge — it would have some serious alternative to convict on.  That’s now one of the options under consideration in the recently announced rape law reform consultation being undertaken by the Department of Justice in Victoria.